The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen. However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry. The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.

Updated: 4 April 2016

The re-opened investigation has gathered a substantial volume of additional evidence, primarily from CASA and the aircraft operator, and has involved over 20 interviews with personnel from the operator and CASA, as well as information from the aircraft’s cockpit voice and flight data recorders. Analysis of the large volume of evidence obtained is continuing as is the development of the draft report, which is now expected to be released for review and comment by directly involved parties around the middle of the year. That analysis is focusing on:

Data from both the CVR and FDR from VH-NGA has been successfully downloaded at the ATSB’s technical facilities in Canberra. The CVR data is of just over 2 hours and 4 minutes duration, covering the period up to the aircraft’s ditching into the waters off Norfolk Island. The FDR contained 116 hours of data, which included the last four flights of VH-NGA, which were undertaken in the period between fitment of the particular recorder to the aircraft on 3 November 2009 and the date of the accident (including the accident flight). The evidence obtained from the recorders will be analysed as part of the ongoing investigation and relevant information will be included in the ATSB’s final report, which is expected to be released in the first quarter of 2016.

Updated: 12 November 2015

During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra. The part numbers and serial numbers of the recorders agree with the maintenance documentation for the aircraft. The recovery and storage of the recorders was witnessed by an officer of the Australian Federal Police. Examination of, and data recovery from, the recorders is expected to commence during the week of 16 November 2015.

Updated: 9 November 2015

In March this year, an underwater survey of the Pel-Air aircraft wreckage was conducted by the ATSB with the assistance of NSW state and federal police officers. The survey was conducted to establish the condition of the wreckage and to assess a viable means of recovering the flight recorders. Subsequently, a commercial marine salvage company, the Pacific Marine Group, was selected through a tendering process to contract with the ATSB to complete the operation. The salvage vessel, PMG Pride, is currently underway from her home port of Townsville and is expected to arrive at Norfolk Island in the next few days.

Early this week investigators from the ATSB, along with an officer from the Australian Federal Police will be working together with the project team from Pacific Marine Group to raise the Pel-Air wreckage and recover the flight recorders. The recorders will be transported back to the ATSB headquarters in Canberra for download and analysis. The data on the ‘black boxes’ will be used to further assist the ATSB investigators understand the sequence of events of the accident.

The ATSB requests that all local vessels remain away from the Pel-Air wreckage site throughout next week. The PMG Pride will be at anchor and there will be divers and salvage equipment in the water.

Updated: 19 October 2015

On 12 June 2015, the ATSB released a Request for Tender for provision of services for the recovery of the flight recorders from VH-NGA. After an extensive evaluation process in accordance with federal government requirements, a successful tender was selected and the ATSB has entered into a contract for a recovery operation to commence on site between 3 and 8 November 2015. The recovery operation is expected to be complete by the middle of November. A further update will be released after examination of the recorders at the ATSB’s technical facilities in Canberra and assessment of whether they contain recoverable and usable data.

The previous update on 25 May 2015 outlined the nature of the other investigation activities being undertaken by the re-opened investigation. These activities are close to being completed. In addition, the re-opened investigation has conducted interviews with both flight crew and both medical crew from the accident flight.

The investigation team are now in the process of analysing the available information and they have commenced the preparation of a draft report. Given the delay in recovering the recorders and the amount of information that has been collected and analysed, it is expected that a draft report will be released to directly involved parties for comment in early 2016.

How the ATSB expunges the shame of its original and highly unprofessional inquiry into the Pel-Air ditching remains to be seen
Ben Sandilands — Editor of Plane Talking
Ben Sandilands

Editor of Plane Talking
The wreckage of the Pel-Air jet which the ATSB originally refused to recover
The wreckage of the Pel-Air jet which the ATSB originally refused to recover

The ATSB has updated the status of its re-opened inquiry into the Pel-Air ditching of an air ambulance flight near Norfolk Island almost seven years ago.

It says it is now “in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.”

This whole sorry saga has become as much about the honesty and diligence of Australia’s air safety investigator, the ATSB, as well as its safety regulator CASA as it has about a plane crash.

In December 2014 the ATSB was directed to withdraw and re-open its original and much criticised report into the ditching following some very serious shortcomings that were identified by an independent peer review by the Transportation Safety Board of Canada.

It took a Senate inquiry to establish that the original ATSB inquiry ignored a suppressed internal CASA report that found the accident could have been avoided had the safety regulator done its job in relation to the oversight of Pel-Air’s operations of the small Westwind corporate jet that it used for medical flights.

The ditched Pel-Air flight involved a medical transfer from Apia to Melbourne which found itself unable to land in very poor weather conditions for its intended refueling stop at Norfolk Island with six people on board. The jet had insufficient fuel on board to to divert to an alternative airport. It was ditched in the sea adjacent to the island before its fuel would have run out and deprived the pilots of full control of the Westwind.

The evidence given by the then chief commissioner of the ATSB, Martin Dolan, to a Senate committee inquiring into its conduct of the original safety investigation was severely criticised in its report.

The Senate disclosures led to widespread concerns in the aviation industry that two government agencies, CASA and the ATSB had conspired to suppress evidence that the regulator had failed in its duty and that the accident report that was subsequently withdrawn had in effect framed the captain of the Pel-Air flight.

Irrespective of the fierce arguments that the original ATSB report gave rise to, there are few precedents for a national air safety regulator to be so totally discredited for its handling of an air crash inquiry as to have to withdraw its original report and do the job again, properly.

Even though the Pel-Air crash occurred in 2009, the failed regulatory reform process in CASA has not yet fully addressed and reformed the claimed inadequacy of the original rules that applied to oceanic medical flights on the night it crashed, leading to an against-all-odds search by a Norfolk Island fishing boat which rescued all six people who had been onboard the ditched jet.

The ATSB which had resolutely refused to recover the the Westwind’s flight recorder finally retrieved it and some other wreckage from the sea bed last year, after it was ordered to do a new investigation.

(The media was left in no doubt that the ATSB was directed to carry out the new inquiry, even though the current posting on its web site makes it sound like it acted on its own initiative.)

The surviving parties in this crash will now be given a period of time in which to review the draft report and have any comments or responses they may make taken into account before the final document is published publicly next year.